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HomeMy WebLinkAbout14684 (19) � � � � �� CITY OF DIAMONp BAR ' DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � � 21660 E.Copley Drive Suite 190 � ' „,�,,,..� (909)86Q3195 Fax(909)861-3117 L PRESS BUILDING PERMIT APPLICATYON ,.__... FIRMLY j � JOBSITE !` �� o ADDRE55 � �3�� 'Z GOL� �rLf DA�CATION 1( NUMBER ' #/C 4� ISSUE TYpE OCC � � APN LOT g TRACT DATE CONST. GROUP p OWNER —A�� � 1 �I�-C�� ---�� o ADDRESS ZONING SETBACKS W CITY ZIP TEL. S�OZ. {p FRONT RW !_ ❑___ � APPLICANT TE - � REAR ❑__ � SIDE/SIDE STREET RW U CONTRACTO �' � SIDE �7__ ADDRESS � CITY ZIP TE � PROPOSEDUSE�•�" ( Z$�OJ� }�,p� �����,1 w ARCWENG/ � ��" — � z DESIGNER--����-�(���i�N� V W t�. W NO.DWEt. �NO. NO. a, ADDRESS � CITY ��. �„�. _ ZIP TE . � UNITS STORIES �__.BEDROOMS u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ; .p� OWNER-BUILDER DECLARATION SFR/ADD/REM � � - O p I MEflEBY AFFlPAI UNDER PENALT'OF PERJUAV 7HA7 I AM EXEMP7 FROM THE CONTRACTORS LI� � G8f8Q8/CefPOrt W' CENSEUWWR7HEFOLIOWINQREASON(SEC,7037.SBUSINESSAN�PfiOFESSIDNSCODC-:ANVCITYOR ' (n C1 WUNTYWHICHRC-0UIRESAPERMITTOCONSTF3UCT,AL7Efl.IMVROVE,DEMOLISH,OqREPAIRANVSTRUC- � �.L Pa110/DBCk Z''' TURE.PRIOR TO ITS ISSUANLE.RL50 REQUIRES'rHE APPLICANT FOR SUCH PEflMIT TO FILE A SIGNED �. w STATEMENT 7HAT HE OR SHE IS UCENSEO PURSUPNT TO THE PROVISIONS OF THE CANTRAC'fOq3 LI: • W �� CQJSE LAW(CHAPTER e(CAMMENCING N77H 6ECTION 7000)OF D�VISION 3 0F THE BUSINESSAND PR0- '' � POOUSP2 � FESSIDNSOOOqORrF1AiHEORSHEISE%EMPTTHEREfROMANpTHEBASISFOHTHEALLEGEDEXEMP- � '� TIIXJ.M/YVKKATIONOFSECTION7031.6BYANYAPPLICANTFORAPFRMITSU&IECTSTHEAPPLICANTTO � z qe•Root � AqVILPENALTYOFNOTMORETHANFNEHUNDflEDDOLVRS(5500).): ' ❑I,ASOWNEHOFTHEPROPEFlTY,OHMVEMPLOYEE6WITHWAGESASiHEIR60LECOMPENSATION, : CortlfitO�Clfl1 ' g: WiLL DO THE WOHK,PND THE STNUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,AUSI- - �J NESSANO PROFESSIONS LO�E:THE CONTRACTORS LICENSE LAW OOES NOT APPLY TO PN OWNER OF � � PROPEHiYYlF108U�1A50NIMPROYESTMLREON,ANDIYHOOOESSUCHWORKHIMSEIFOHHERSELFOR ! � �� THROUGHHISORHEROWNEMP�OYEES,PROVIOEDTHATSUCHIMPROVEMENTSAqENOTINTENOEDOR . m W OFFEHFDWH3ALEIF,HOWEVERTNEBUILDINGORIMPROVEMEMISSOLOWITHINONEYEAROFCAMPLE- ' ��' 'TIDN,THE OWNER$UILDER WILL HAYE THE BUH�EN OF PROVING THAT ME OR SHE DIO NOT 6lJIlD OR :, Z' IMP{i�VEFORTHEPURPOSF.OFSRLE}. ' u,�' ❑I,ASONRIENOFTHEPROPERfI:AMEXCLUSIYELYCONTMCTINGWITHLICENSEDCOMRACTORS ' �'� TO CONSTqUCT iHE PROJECT(SEC.7DI4,BUSINE55 AND DROGF.SSIONS CODE:THE CONTRACTORS LI-. ' VOIlId110 ADJ.AREA W; CENSELAWDOESNOTAPPLYTOAN�WNEROFAPROPERTYWNOBUi050RIM7ROVE5THEREON,qNO ? �� - --- -------- - �. W1qCONTMCT3FOR5UCNPR0.1ECT5WITHACONiMCTOR(5�UCENSE�PUfiSURNiTOTMEGYNJTMC• ' QUANTI. DESCRIPTION FEE �x TORSLICENSELAW.). �� ❑i RM E7(EMFf UNOER SEG _,.,0.A P.G FOR THIS REASON J .O.. , O. � 'e- }i` ---- -- ¢ "�l�J � u"�� �ATE_- aWNER—__—_ F Z� _ _-_'_ '- . W F' LICENSED CONTRACTORS DECLARATION W .. �� IHEREBYqFFIR1AUNOERPENqI,TYOFPERIURY?4AT:AMLICENSEDI:N�Efi7ROVI510N50FCHAPTtR � ' �� �. d� B(COMMENGINOWI'fH5ECT10Fl7o0o)Of01VI510N30FTHEBUSINESSANPPflOFE5510N5CAp[,AND � Z Xi MY LICENSE 6�N FULL FORCE AND EFFECT. m �a.i `� �a �„ UCENSE CU1S ~ � LIC.NO. `'• Z � �' � �7. �i —.' __— V, DATE_ � CON7PACTOR_Ml]�_�_ A W( ///��� �� WORICEHS'COMPENSATIONDECLARATION. � J (/ , , � IH[REBYRFFIRMUN�ERPENPLTYOFPEfiJURVONEOFTHEFOLLOWINGD LARAiIo . -f � �� � � ��� �- � � � �� cN z O _INAYEAiJDWILLiAA1NTAINACERTiFICATEOFCONSENTTOSF:L INSUflEFORW RKER _— �� COMPENSATION,ASPROVIDEDBYSECTION37ooOFTHF.U90.CODE,FORTH[PERFC W OF THE WORK FOR NMICH THIS PF.RMIT IA ISSUEU. � � W __I HAVEAND WILLIAAINTP.IN YIORKEFS'COMPEhSAiION INS�RpYCE,AS RE�UIRF.D BY SECTION ' � p 87000FTHEtABORCODE,FOHTHEPERFORMANCEOFTHEWORKFOHWHICMiHISPERMRIS . ISSUEO.MV WORKERS'COMPENSATION IN IJR CE CARRIE AND��OLICY NUM6ER AFE TION ___ _ _ .'� �� p ---33 _ - . Q CARHIER��'lE'�C' �-� q ... 'S_. • F N REVI . �-.�. ..---__' . > —.. __... ....—.-..--- • �.,: n POLICYNUM�ER__� � �' �rf--__ �(�,Tfll �' � ___.. . ., y d l% �`�"� 0 (M55ECTIONNE�NO76EOOA4'I.FfFDCFTiEPERhYiISFORCNE . D�L irol P G ___�_—!� "`� ._._ �. --- --� w I CERTIFY THAT INTHE PERFORMMCE OF THE WOHK FOq WHIC HIS PEPMIT S ISSUEO,I CHANICAL .. Z _...-._ �. . �,. (3 SHALLNOTEMPLOVANVPERSONINMlYMANNERSOASTOBE MF.SU&IECTTOTHE _ ! - y�. WORKERS'COAIPENSATKKJ LAWS oF CAIIFOflNIA,AND AGflEE NAT IF I SHOJI�BEGOk.E NSPECTION FEE ___, ,_._ ___ ___ ' SU&IECT TO THE WOFKEflS'CAMPENSATION PROVISIONS OF CTION 3� Ofl • � � CODE.ISMNIFORTMWITHCOMPLYWI OSEPFOVISIONS. ISSUANCE ,___ __ �{�g�� _ � �t � SMIP �/� "'_ p DATE: ,�� APPLiCANT: �-- �—K ���= J W .�r ��._. _��-_ � , �� J WARNINGFAIL ETOSECUREWORKERS'COMPENSAfIONCOVERAGElS aWfUL,AN�SHALLBE ENERGVPlC _.,.,.,..._. ._., . i7c�+_ �y SU0.IECTANEMPLOVERTOCFIMINALPF.NALTIESANDCIVILFINESUPTO EHUNDREOTHOUSAND ENERGYPERMIT I� O���� � � � OOLLAHS(f1o0.oao),INAD�I710NTOTHF.00.STOFCOMPEN9ATION,DAN ESASPROVIDEDF'ORIN -- ----��-- _„ ���_-'� � SECTION37080FiHF:1.ABORCODE,INTERESi,ANDATTORNEI"SFEES. _ _ 7'yS l]1'y>°" RETEN710N FEE: yl�__ a CONSTRUCTION LENDING AGENCY PRE- LT F __,___,_. ,__ ._ I � IHEflEBVAFFIRMUNDERPfNALTYOFPERJURYTHATTHEREISACON5TqL1CTION4ENDINGAGENCV /I`���� __ � . . FOp THE PEI1fORA1ANCE Or THE WORK FOR WNICH h115 PERMIT IS ISSUED(SEC.3097,CIV.CJ. -�� W —' . � LENOEfi'SNAME ..__-""_-_' "—' ._' __""" "'__ _ F- LENDER'SADDRE55____�_ ___--.— _--_ � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETFiATTNEABOVEINFORMATIONISCORFiECT. TOTAL FEES ( 1,� i'� . � I AGHEE TO CAMPLY Wlhi ALL CITV AND COUNTV ORDINANCES AND STATF.U1WS RELATING TO BUI4DING �/�, � �/ � CONSTNUC710N,PNOHEREBYAUTHORI2EREPRESENTATIVESOFTHISCOUNTYTOENTEqUPONTHE � I��I�n-.. _-' �C�yn� �^ ,/1 Z A90VE�ME ED PROPERTV FOR INSPE ION PURPO5E5. /`r1:�! G�v l/v� o �� r � M PJTS � .��L��_ 1 - m �_ , _� ¢ PERMITT AME(PRINT� 7� __' _"' �'--� /��T _'__' - — � �SIC�EE ,., TE ��- -. —���,( 'VI � _ � RECPT.NO PAID BY �._.____ VALIDATION - ITE—Department Copy,YELLOW—Finence Capy,PINK—Assassor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy . �__, �._ € 4 i ' I I r '; , „ � � ' ��� � . �� � ''..._. {. .��` � .' f .m ,:...... ' ...' s f , ' j �, i �� k j `., r ��.I M1 [ � . k p t � 5 y�f H +�'—4 . � i _ . ' I i ' ! V i ..'. � 1 Yd' p � � �R�� t.. � � � 1� ' ' - � � - � � fi;-) . 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